Patient Presentation
A 6-year-old male came to clinic for a flare of his atopic dermatitis.
His mother had noticed that his elbows were much worse in the past few days and one area was now becoming weepy.
He was afebrile and his mother denied any new soaps/lotions/detergents/etc. His mother said that she was using copious amounts of emollients, was following the recommended bathing procedures and was giving him diphenhydramine for itching.
She had tried 1% hydrocortisone cream for the past 2 days on his elbows.
His past medical history showed mild persistent asthma that he was taking a low-dose inhaled daily steroid for, but his mother stated that she didn’t give the medication every day because she was worried about the steroids.
The past medical history showed that he had been hospitalized for asthma at age 2 and had 2 other emergency room visits for asthma.
The family history was positive for atopic dermatitis, allergic rhinitis and asthma in both sides of the family.
The review of systems was negative.
The pertinent physical exam showed a non-ill appearing child with normal vital signs and growth parameters in the 25-50%.
He had some atopic pleats around his eyes and some moderate clear nasal discharge.
His skin was generally dry with significant redness and swelling bilaterally in the flexural areas of the elbows and knees, and around the wrists.
The left elbow also had some intact pustules and other areas with yellowish discharge covering an area where a pustule had been unroofed.
The rest of his examination was normal.
The diagnosis of an atopic dermatitis flare with secondary bacterial infection was made.
The physician prescribed mupirocin cream for the secondary bacterial infection and increased the steroid from a group VII to a group VI steroid cream.
Additionally, he reiterated the proper use of all the medications including the emollients. He also talked with the mother about daily steroid inhaler and its necessity.
She was still reluctant to give it to him on a daily basis. The physician considered changing to a leukotriene modifier medication.
He said that he knew that it was recommended for the asthma but thought that it may also have some effects on atopic dermatitis since other immunomodulators like tacrolimus were used for atopic dermatitis.
The mother said that she would be willing to consider it for his asthma but wanted to think some more about it.
The physician did an Internet PubMed search, searched for practice guidelines and reviewed the manufacturers information about montelukast (Singulair®).
This information did not support using montelukast as a treatment or atopic dermatitis. During a telephone call, the mother said that the atopic dermatitis was improving with the treatment and agreed trying the montelukast for his asthma.
Discussion
Atopic dermatitis is a common skin condition that occurs in 10-15% of children. It is chronic, relapsing and has an immunological basis but the exact etiology is unclear.
The clinical presentation varies from mild to very severe.
In acute presentations the skin can have erythematous papules and/or vesicles that overly erythematous skin. There are frequently excoriations and erosions.
In subacute presentations there will be erythema, excoriations and scaling of the skin.
In chronic presentations the skin will have progressed to having thick plaques of skin, lichenification and/or fibrotic papules.
One recent study found that childhood atopic dermatitis increased the likelihood of childhood asthma, asthma persisting into middle age, and new-onset asthma in later life.
Learning Point
Treatment of atopic dermatitis consists of skin hydration with emollients, avoiding precipitators (often allergic), using topical corticosteroids and systemic antihistamines, and using antibiotic coverage for secondary infections.
Corticosteroids are a key medication in atopic dermatitis treatment but have many unwanted side effects including thinning of the skin, striae, rosacea, and telangiectasia. Systemic absorption and potential suppression of the pituitary-adrenal axis has also been documented, but luckily is uncommon.
Immunomodulators are potential alternatives but can be much more expensive.
One systematic review found topical pimecrolimus (a topical calcineurin inhibitor and immunomodulator) to be less effective than moderate to potent corticosteroids and 0.1% tacrolimus (a different calcineurin inhibitor).
This review also noted that there was little data comparing pimecrolimus against mild-potency corticosteroids.
Another review noted that “the safety profile of topical tacrolimus and pimecrolimus looks reassuring to date, and can be used for people who become ’stuck’ on topical corticosteroids, especially on sensitive sites such as the face.”
At least theoretically, oral immunomodulators could also be effective. One study of a double-blind, placebo-controlled trial of montelukast in 54 adults with atopic dermatitis did not find any significant differences in treatment response and therefore did not support using it.
Oral cyclosporin can be used for severe atopic dermatitis remission induction and azathioprine can be considered for maintenance therapy.
A state-of-the-art review article on atopic dermatitis shas recently been published in Pediatrics which includes a review of the medications as well as step-by-step instructions for other care such as wet wraps and bleach baths.
Questions for Further Discussion
1. What other treatments are recommended for mild persistent asthma?
2. When should a dermatologist be consulted for atopic dermatitis?
3. What is the difference between atopic dermatitis and eczema?
Related Cases
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Eczema
and at Pediatric Common Questions, Quick Answers for this topic: Eczema
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Spagnola C, Korb JD. Atopic Dermatitis. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/topic2567.htm (rev. 05/24/06, cited 11/11/08).
Chang C, Keen CL, Gershwin ME.
Treatment of atopic dermatitis.
Clin Rev Allergy Immunol. 2007 Dec;33(3):204-25.
Friedmann PS, Palmer R, Tan E, Ogboli M, Barclay G, Hotchkiss K, Berth-Jones J.
A double-blind, placebo-controlled trial of montelukast in adult atopic eczema.
Clin Exp Allergy. 2007 Oct;37(10):1536-40.
Topical pimecrolimus for atopic dermatitis.
Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005500.
Burgess JA, Dharmage SC, Byrnes GB, Matheson MC, Gurrin LC, Wharton CL, Johns DP, Abramson MJ, Hopper JL, Walters EH.
Childhood atopic dermatitis and asthma incidence and persistence: a cohort study from childhood to middle age.
J Allergy Clin Immunol. 2008 Aug;122(2):280-5.
Krakowski AC, Eichenfield LF, Dohil MA.
Management of atopic dermatitis in the pediatric population.
Pediatrics. 2008 Oct;122(4):812-24.
ACGME Competencies Highlighted by Case
Patient Care
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
8. Health care services aimed at preventing health problems or maintaining health are provided.
Medical Knowledge
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Practice Based Learning and Improvement
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
Interpersonal and Communication Skills
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Date
December 8, 2008
